Advanced Endoscopy for Benign Esophageal Disease: A Review Focused on Non-Erosive Reflux Disease and Eosinophilic Esophagitis

Abstract

Advanced endoscopy (AVE) techniques include image-enhanced endoscopy methods, such as narrow-band imaging (NBI), and types of microscopic endoscopy, such as endocytoscopy. In the esophagus, AVE first showed diagnostic utility in the diagnosis of superficial esophageal cancer and was then applied to inflammatory disease. This review focuses on non-erosive reflux disease (NERD) and eosinophilic esophagitis (EoE), which sometimes show no abnormal findings on standard white light endoscopy alone. Studies have demonstrated that advanced endoscopy, including NBI magnification endoscopy and endocytoscopy, improved the diagnostic performance of white-light endoscopy alone for NERD and EoE. In this review, we explain why advanced endoscopy is needed for the diagnosis of these esophageal inflammatory diseases, summarize the study results, and discuss future perspectives.

Keywords: endocytoscopy; endoscopic diagnosis; eosinophilic esophagitis; esophagus; gastroesophageal reflux disease (GERD); image enhanced endoscopy; magnification endoscopy; narrow-band imaging; non-erosive reflux disease (NERD).

Figure 1

A 28-year-old male patient suffered from postprandial heartburn. The F-scale, which is a questionnaire scoring system for GERD, showed 27 points in this patient, which suggests reflux esophagitis since the result is higher than 8 points. WLE shows minimal changes in a white turbidity area with invisibility of palisade vessels along with slightly irregular z-line (a). LCI can visualize the minimal changes more clearly than WLE (b). BLI-ME demonstrates an increased number of dilated microvessels (IPCLs) in the white turbidity area (c). After taking a proton pump inhibitor for 4 weeks, the F-scale score decreased from 27 to 5 points. Color changes in white turbidity reduced on both WLE and LCI images ((d,e), respectively). BLI-ME shows that palisade vessels are visible and the severity of increased and dilated IPCLs reduces (f).

Figure 2

A 52-year-old male was referred to our university hospital because of heartburn and dysphagia that was refractory to proton pump inhibitors. WLE and imdigocarmine chromoendoscopy revealed linear furrows, exudates, and rings in the upper and middle esophagus (a,b). NBI-ME showed a beige-colored mucosa and dot-shaped IPCLs in the mucosal sites without visibility of cyan vessels (c). Endocytoscopy (magnification ×520) demonstrates multiple cells with purple bilobed nuclei with a nonstained periphery ((d), white arrowheads). This finding was suggestive of eosinophilic infiltration. Biopsy samples were collected at the site of endocytoscopic observation. The histology showed >50 eosinophils, several showing bilobed nuclei per high-power field ((e), white arrowheads showing representative bilobed nuclei of eosinophilic cells).